Provider Demographics
NPI:1821679390
Name:BENNETT, JOHN F (MR)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N GREENVILLE AVE
Mailing Address - Street 2:SUITE C # 15
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002
Mailing Address - Country:US
Mailing Address - Phone:469-236-4511
Mailing Address - Fax:
Practice Address - Street 1:1407 ORCHID DR UNIT A
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:TX
Practice Address - Zip Code:75407-1240
Practice Address - Country:US
Practice Address - Phone:469-236-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2201156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist